The results are in from the only completed Adrenaline (Epinephrine in non-Commonwealth countries) vs. Placebo for Cardiac Arrest study.

Even I overestimated the possibility of benefit of epinephrine.

I had hoped that there would be some evidence to help identify patients who might benefit from epinephrine, but that is not the case.

PARAMEDIC2 (Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration in Cardiac Arrest) compared adrenaline (epinephrine) with placebo in a “randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest”.

More people survived for at least 30 days with epinephrine, which is entirely expected. There has not been any controversy about whether giving epinephrine produces pulses more often than not giving epinephrine. As with amiodarone (Nexterone and Pacerone), the question has been whether we are just filling the ICUs and nursing home beds with comatose patients.

There was no statistical evidence of a modification in treatment effect by such factors as the patient’s age, whether the cardiac arrest was witnessed, whether CPR was performed by a bystander, initial cardiac rhythm, or response time or time to trial-agent administration (Fig. S7 in the Supplementary Appendix).[1]

The secondary outcome is what everyone has been much more interested in – what are the neurological outcomes with adrenaline vs. without adrenaline?

The best outcome was no detectable neurological impairment.

the benefits of epinephrine that were identified in our trial are small, since they would result in 1 extra survivor for every 112 patients treated. This number is less than the minimal clinically important difference that has been defined in previous studies.29,30 Among the survivors, almost twice the number in the epinephrine group as in the placebo group had severe neurologic impairment.

Our work with patients and the public before starting the trial (as summarized in the Supplementary Appendix) identified survival with a favorable neurologic outcome to be a higher priority than survival alone.[1]

Click on the image to make it larger.

Are there some patients who will do better with epinephrine than without?

Maybe (I would have written probably, before these results), but we still do not know how to identify those patients.

Is titrating tiny amounts of epinephrine, to observe for response, reasonable? What response would we be looking for? Wat do we do if we observe that response? We have been using epinephrine for over half a century and we still don’t know when to use it, how much to use, or how to identify the patients who might benefit.

I will write more about these results later

We now have evidence that, as with amiodarone, we should only be using epinephrine as part of well controlled trials.

When faced with death, we can become desperate, stop thinking clearly, and just try anything.

Alternative medicine thrives on the desperation of people who are not thinking clearly. We should be better than that, but are we?

A recent comment on The Myth that Narcan Reverses Cardiac Arrest[1] proposes that I would suddenly give kitchen sink medicine a try, if I really care about the patient.

Kitchen sink medicine? It’s better to do something and harm the patient, than to limit treatment to what works. Throw everything, including the kitchen sink, at the patient.

Mike Karras writes –

I will leave you with this question sir and I am interested to hear your answer. You walk in to find your 14 year old daughter that intentionally overdosed on morphine in a suicide attempt and she is in cardiac arrest. How would you treat her? Would you give her Narcan? I think you would.[2]

Mike, I am thrilled to read that you do not think that I care about the outcomes of my patients, unless the patient happens to be my daughter. I am even more thrilled that you made my imaginary daughter suicidal.

No, I would not use naloxone (Narcan).

I would also not use homeopathy, acupuncture, sodium bicarbonate, incantations, or magic spells to treat my daughter during cardiac arrest. Voodoo only works on believers, because voodoo is just a placebo/nocebo.[3]

Does really wanting something to be true make it true? If you believe in magic, the answer is Yes, believing makes it true. If you examine the evidence for that belief, you have several choices. You can acknowledge your mistake, or you can employ a bit of cognitive dissonance, or . . . . Cognitive dissonance is the way our minds copes with the conflict, when reality and belief do not agree, and we choose to reject reality.[4]

If the patient is suspected of having a cardiac arrest because of an opioid overdose (overdose of heroin, fentanyl, morphine, . . . ), the treatments should include ventilation and chest compressions. If those do not provide a response, epinephrine (Adrenaline in Commonwealth countries) is added.

An opioid overdose can produce respiratory depression and/or vasodilation. I can counter both of those with chest compressions, ventilation, and maybe epinephrine. Naloxone works on opioid receptors. What does naloxone add?

Does naloxone’s stimulation of an opioid receptor produce more ventilation than bagging/intubating?

Does naloxone’s stimulation of an opioid receptor produce more oxygenation than bagging/intubating?

Does naloxone’s stimulation of an opioid receptor produce more vasoconstriction than chest compressions and epinephrine?*

*Late edit – 02/17/2015 10:52 – added the word naloxone’s to the three sentences about the relative amount of stimulus provided by standard ACLS and by the addition of naloxone. Thanks to Brian Behn for pointing out the lack of clarity.

A nocebo is an inert agent that produces negative effects. What this means is that nocebo effects are adverse placebo effects. There is no reason to believe that placebos only produce positive effects or no effects at all.

DocXology did not like my criticism of the futility of CPR in trauma –

I think you are setting up a straw man with your naloxone argument. There is not even biomedical plausibility for the scenario you describe.

What did I write?

While CPR in the pulseless trauma patient has overall been considered futile, several reversible causes of cardiac arrest in the context of trauma are correctible and their prompt treatment could be life-saving.[1]

This is a non sequitur.

Where is there any evidence that CPR in any pulseless trauma patients is not futile?[2]

Then I substituted naloxone for CPR in the argument in order to demonstrate that treatment of a potentially reversible cause has absolutely nothing to do with providing a futile treatment in the mean time.

It does not matter if the futile treatment is CPR in traumatic arrest, naloxone in cardiac arrest, or homeopathy for any medical condition. Providing a useless treatment is still useless.

Doing something useless, just for the purpose of looking like we are doing something, is not useful. This only distracts us from whatever might be useful.

One way of improving the fuel economy of a vehicle is to turn off the air conditioning and other items that make the engine work harder and burn more fuel. If the vehicle is out of fuel, then turning off the air conditioning is not going to matter. It is a futile response, just as CPR is a futile response to traumatic cardiac arrest.

The whole point of what I wrote is to demonstrate that the argument for CPR in trauma lacks biological plausibility.

Is that a straw man argument? My argument is not a straw man. Whether DocXology’s argument is a straw man, or just a misunderstanding, is not clear.

There is no RCT to say that oxygenation is good for cardiac arrest but there is a good physiological rationale for it. I presume you don’t withhold that?

That depends on the bias one uses in interpreting the evidence that is the basis for physiological hypotheses.

We started using oxygen for resuscitation because it seemed like a good idea. Now we use it because we always have.[3]

WHAT’S KNOWN ON THIS SUBJECT:
The superiority of room air over 100% oxygen for resuscitating asphyxiated term and near-term newborns has been demonstrated. However, results of studies of preterm infants have indicated that room-air resuscitation may not be appropriate for this population.

WHAT THIS STUDY ADDS:
Resuscitation of preterm infants starting with 100% oxygen followed by frequent titration was most effective at achieving a target oxygen saturation while avoiding hyperoxemia. Treatment-failure rates were highest for those resuscitated with room air despite rapid titration of oxygen.[4]

As with most treatments based only on the contemporary understanding of physiology, the good physiological rationale for it is being demonstrated to be an overly optimistic interpretation of what we really know.

Oxygen is a drug that should be titrated to the effect that is best for the patient.

This does not mean that physiology is unimportant, but that treatments based on physiology must be demonstrated to work in real patients before being widely adopted.

Then there is the question of how much physiology really supports the use of supplemental oxygen at high flow rates, rather than just to maintain a normal oxygen saturation.

Numerous laboratory investigations have identified a paradox relative to oxygen delivery to the injured brain. Although it is intuitive that insufficient oxygen delivery can exacerbate cerebral anoxia, excessive oxygen delivery can also be harmful by exacerbating oxygen free radical formation and subsequent reperfusion injury.4,–,11[6]

My protocols only require that oxygen saturation be maintained at 94% or above.

Supplemental oxygen is not required if the oxygen saturation is adequate.

You suggest that the physiological rationale is unambiguous on oxygen for resuscitation.

That is not true.

I appreciate the issue of withholding ECM (Excternal Cardiac Massage) for traumatic arrest. It was raised at ICEM 2012 by Prof Harris of HEMS and he quoted animal studies with the argument the heart in hypovolaemic PEA is maximally hyper-dynamic and further mechanical augmentation is unlikely to improve output. But again no RCTs or human studies to support this.

Routine treatments should not be based on the absence of evidence of harm, otherwise we could justify anything at all that has not been demonstrated to be harmful. That is not medicine.

Medicine has evidence of efficacy.

Where is the evidence of efficacy for CPR in traumatic cardiac arrest?

Where is the physiologic rationale for CPR in traumatic cardiac arrest?

Treatments without evidence of efficacy should be limited to controlled trials.

We need to stop using wishful thinking to justify abuse of patients.

There is presentation on resuscitation by Dr. Tim Harris available as a free mp3 download at Free Emergency Medicine Talks, but I did not notice any reference to CPR for traumatic cardiac arrest. There are several skips in the recording, but the skips do not appear to obscure information necessary to understand the points Dr. Harris is making. Did he have another presentation on resuscitation?

We are supposed to search for the potentially reversible causes of cardiac arrest and treat those causes. Since naloxone (Narcan) is the most familiar antidote out there, many people assume that we should be giving naloxone.

Narcan is in the ACLS (Advanced Cardiac Life Support) guidelines!

What do the ACLS guidelines actually state about naloxone?

Naloxone is a potent antagonist of the binding of opioid medications to their receptors in the brain and spinal cord. Administration of naloxone can reverse central nervous system and respiratory depression caused by opioid overdose. Naloxone has no role in the management of cardiac arrest.[1]

Naloxone has no role in the management of cardiac arrest.

Yes. Naloxone is in the ACLS guidelines, but the guidelines say naloxone is not for cardiac arrest.

But what if I really, really, really want to give Narcan?

We can give naloxone, but we shouldn’t pretend that we are following ACLS guidelines.

What about the Hs and Ts?

ACLS does state that we are supposed to consider the potentially reversible causes and to give a treatment that has the potential to improve the outcome. ACLS clearly states that naloxone is not one of those treatments.

Opioid overdose is a potentially reversible cause of cardiac arrest, but naloxone is not the recommended treatment. Opioids do not require administration of an antidote for resuscitation.

But at least Narcan is safe!

Opioid Depression
Abrupt reversal of opioid depression may result in nausea, vomiting, sweating, tachycardia, increased blood pressure, tremulousness, seizures, ventricular tachycardia and fibrillation, pulmonary edema, and cardiac arrest which may result in death (see PRECAUTIONS).[2]

That is not a description of safe.

Safety depends on the context.

Yesterday I wrote about giving naloxone to an intubated patient who had good vital signs after a couple of minutes of chest compressions.[3] There are many ways that naloxone could have made things worse and only one way that it might have helped. That is not the kind of context where naloxone is safe. The medic got lucky.

Why go looking for trouble?

We get invited to enough trouble already.

In normal subjects anaesthetised with morphine and nitrous oxide,3 and in patients addicted to narcotics, pulse rate and blood pressure increase appreciably after reversal of the effects of opiates. Presumably naloxone antagonises opiate suppression of the sympathetic system resulting in a sudden increase in its activity.[4]

We could protect against this unwanted sympathetic stimulus by giving another drug, but how many drugs are we going to give to a patient who is already stable to try to produce a stable patient?

Clonidine might possibly be useful because it abolishes increases in pulse and blood pressure after reversal of opiate effects with naloxone.5[4]

I am very aggressive in treating many things (e.g. high doses of nitrates for CHF, high doses of opioids and/or benzodiazepines), but these are supported by documentation of safety in the way that I use them.

One caveat. This does not apply to a medical cardiac arrest that coincidentally has some trauma associated with it. V Fib (Ventricular Fibrillation) while driving leading to a car crash. That is not a trauma arrest.

–

What is the purpose of CPR in trauma arrest?

To put on a show.

–

[youtube]e7mmrF-4rUE[/youtube]

–

Bullwinkle is infinitely more likely to pull a rabbit out of that hat, than CPR is likely to resuscitate a cardiac arrest due to trauma.

Play the video again, it might work.

Almost.

Keep trying.

Nearly had it.

Don’t give up.

You were so close.

Maybe this time.

There was tremendous improvement on that attempt.

Never say die.

Couldn’t you feel that it was there?

Under no circumstances will we admit that our magic is futile!

Keep trying. I know you can do it. You can find that card, Charlie Brown will kick that ball, and nobody ever dies. 😉

BLS and ACLS for the trauma patient are fundamentally the same as that for the patient with primary cardiac arrest, with focus on support of airway, breathing, and circulation. In addition, reversible causes of cardiac arrest need to considered. While CPR in the pulseless trauma patient has overall been considered futile, several reversible causes of cardiac arrest in the context of trauma are correctible and their prompt treatment could be life-saving. These include hypoxia, hypovolemia, diminished cardiac output secondary to pneumothorax or pericardial tamponade, and hypothermia.[1]

While CPR in the pulseless trauma patient has overall been considered futile, several reversible causes of cardiac arrest in the context of trauma are correctible and their prompt treatment could be life-saving.

This is a non sequitur.

Where is there any evidence that CPR in any pulseless trauma patients is not futile?

There isn’t any.

None. That is why CPR for pulseless patients is considered futile.

This is just a case of treatment based entirely on What if . . . ?

This is alternative medicine. This is not medicine.

–

Here is our good friend naloxone (Narcan) to explain the non sequitur –

While CPR in the pulseless trauma patient has overall been considered futileWhile naloxone in the pulseless trauma patient has overall been considered futile, several reversible causes of cardiac arrest in the context of trauma are correctible and their prompt treatment could be life-saving.

Or –

While CPR in the pulseless trauma patient has overall been considered futile, several reversible causes of cardiac arrest in the context of trauma are correctible and their prompt treatment could be life-saving naloxone can cause withdrawal in opioid addicts.

Are we harming trauma patients by not using naloxone?

What does naloxone have to do with traumatic arrest?

Not a thing.

What does any futile treatment for pulseless trauma patients have to do with reversible causes of cardiac arrest?

But it is only considered futile!

That is because of the difficulty in proving a negative. Hume’s problem of induction does not mean that we should assume that anything that has a snowball’s chance of working actually does work.[2]

–

Should we try Reiki, because What if . . . ?

Should we try acupuncture, because What if . . . ?

Should we try a medicine dance, because What if . . . ?

Should we try therapeutic phlebotomy bleeding the patient to remove the bad humors, because What if . . . ?

Should we sing silly songs, because What if . . . ?

–

What is the cause of pulselessness in trauma patients?

There are 2 possibilities –

1. Obstruction of circulation –

Tension pneumothorax kills by preventing circulation, not by interfering with breathing.

Cardiac tamponade also kills by preventing circulation.

2. Nothing to circulate –

Hypovolemic arrest kills because there is not enough blood to produce a palpable pulse, even though the heart is beating as well as can be expected.

If the compressions do not produce any circulation, what is the point of CPR?

BLS Modifications
When multisystem trauma is present or trauma involves the head and neck, the cervical spine must be stabilized.[1]

Is the outcome from traumatic arrest so good that we need to throw in this ritual? Or is it so bad, that it does not matter what we do to keep up appearances?

If we have time to strap a patient to a backboard, then we might as well just get out a shovel and have the funeral right there. Nothing says permanently dead as clearly as putting spinal immobilization and CPR for trauma together.

All rest and no work makes Jack a cold boy.
All rest and no work makes Jack a cold boy.
All rest and no work makes Jack a cold boy.
All rest and no work makes Jack a cold boy.
All rest and no work makes Jack a cold boy.
All rest and no work makes Jack a cold boy.
All rest and no work makes Jack a cold boy.
😎

–

The 22-year-old South Korean man is in a critical condition with hypothermia, and was put into an induced coma, after being found at Falls Creek in the state’s northeast about 4.30am.[1]

It is unusual for someone to be found at 04:30, but this guy was. Given his temperature, if he had been found at 05:00, he probably would have been pulseless and he probably would not been resuscitated.

“That’s one of the coldest patients that I’ve been to in 30 years of ambulance service,” the Ambulance Victoria clinical support officer said.[1]

24 °C is equal to 75.2 °F. Comfortable as an air temperature. Cool as a water temperature. Very, very cold for a human body.

While this does not appear to be the time of year to consider this, it is in Australia. The difference between hypothermia in the Summer and hypothermia in the Winter is the rate of cooling.

–

Unintentional or accidental hypothermia is a serious and preventable health problem. Severe hypothermia (body temperature <30°C [86°F]) is associated with marked depression of critical body functions, which may make the victim appear clinically dead during the initial assessment. Therefore, lifesaving procedures should be initiated unless the victim is obviously dead (eg, rigor mortis, decomposition, hemisection, decapitation).[2]

–

These patients need aggressive rewarming and they need to be prevented from getting cold again.

For patients with severe hypothermia (<30°C [86°F]) with a perfusing rhythm, core rewarming is often used, although some have reported successful rewarming with active external warming techniques.408,409 Active external warming techniques include forced air or other efficient surface-warming devices.[2]

–

“It’s typically not seen in Australia.

“The only time that these sort of temperatures are recorded in patients that have survived are perhaps in Europe and Canada and the United States.”[1]

Because the temperature does not get low enough to drop a person’s body temperature down to 75 degrees quickly? Why not?

I think that it is rare anywhere. Few of us have treated patients with body temperatures this cold, but still alive. It is important to recognize the problem quickly. Remove wet clothing and dry the patient also quickly.

–

ACLS management of cardiac arrest due to hypothermia focuses on aggressive active core rewarming techniques as the primary therapeutic modality. Conventional wisdom indicates that the hypothermic heart may be unresponsive to cardiovascular drugs, pacemaker stimulation, and defibrillation; however, the data to support this are essentially theoretical.429[2]

In other words, rewarming works. Beyond rewarming, we are guessing. Since the drugs do not appear to improve survival to discharge in normothermic cardiac arrest, there is no reason to expect them to suddenly improve outcomes just because the patient is cold.

I made it a little larger, because I expect that you have already looked at it, and the other ECGs from this patient, in Tom’s post.

The first thing I notice about this 12 lead is that there are only 2 clear QRS complexes in 10 seconds.

If the heart is beating, where is the current in the leads being recorded?

This is a 12 lead. Each portion of the printout is the simultaneous recording of 3 different leads. If there is current it should show up in the other 2 leads in the same section of the 12 lead. It could be that the axis is perpendicular to that lead, but again there are 3 leads, so the axis cannot be perpendicular to all three of the leads simultaneously recorded.[1] The first 12 lead did show Low voltage QRS in the analysis, but it also did show what appear to be QRS complexes in all of the leads.

At 07:44:31 12 lead 1 is recorded with apparent QRS complexes in all leads.

At 08:01:44 12 lead 2 is recorded, but only half of the 12 leads appear to have QRS complexes.

15 minutes later and the ECG looks worse.

The patient is sweaty/clammy/diaphoretic. Whatever terminology we use, the patient is wet. Wet is the enemy of having the leads stick, although wet is an important part of the means of conduction of the electricity to the monitor. How do we quickly troubleshoot our equipment?

Check the pulse.

Is the patient’s heart rate really only 2 beats every 10 seconds?

If yes, that means a heart rate of about 12 beats per minute. The rhythm is irregular and this is a very small sample, but the important point is that a heart rate of 12 in a human is incompatible with survival.

Even extreme athletes do not get their resting heart rates below the 20s and this 82 year old hypertensive diabetic is not an extreme athlete. He is extremely unstable. Another possible explanation would be if the person were hypothermic, but there is nothing in this case presentation to suggest hypothermia.

Tom makes some important points about the way to approach an arrhythmia. One is the potentially reversible causes. This patient is not yet in cardiac arrest, but by treating the potentially reversible condition that is expected to progress to cardiac arrest, perhaps we can prevent a cardiac arrest.

SW: “I know I’ve learned from being burned many times, that when I have a profound bradycardia or heart block, as my residents are getting excited to place in a pacer, even if the patient has no preexisting history, I do a trial of calcium chloride or calcium gluconate because I’ve just had so many cases where it turned out to be hyperkalemia. Is that your experience as well?”

SS: “That is my experience as well and I think it’s very wise you’re giving calcium before you start pacing. By far, more common than intrinsic causes of bradycardia and heart block is hyperkalemia — so common — and so frequently overlooked. It’s a great imitator, I think. There are so many ways the ECG can manifest with severe hyperkalemia — life-threatening hyperkalemia. Again, the treatment is benign, and cheap! So how many life-threatening diseases can you treat benignly and cheaply?”[2]

SW is Scott Weingart, M.D. SS is Stephen Smith, M.D.

While calcium is not generally in EMS protocols for bradycardia, we should consider these critical statements by Dr. Smith –

I think it’s very wise you’re giving calcium before you start pacing.

and

Again, the treatment is benign, and cheap!

A lot of people do not seem to be familiar with the word benign.

–

adjectiveDefinition:

1. kindly: having a kind and gentle disposition or appearance

2. not life-threatening: not a threat to life or long-term health, especially by being noncancerous
a benign tumor

What if the low amplitude/no amplitude of the QRS complexes the 12 lead claims are there really are there? Would that be an indication of hypokalemia?

No.

The beats that are clearly present are not giving any indication that the patient is hypokalemic.

The beats that I do not see, but the 12 lead counts are probably not there, but definitely not being hidden by hypokalemia.

Why does the machine come up with a different heart rate from what I come up with?

The machine could be wrong.

I could be wrong.

Both of us could be wrong.

The best way to assess this is to actually touch the patient and assess for the presence of a palpable pulse.

It is interesting that the 12 lead does not make any suggestion about considering hyperkalemia, while the doctors think that unstable bradycardia is a good reason to automatically treat for hyperkalemia.

–

What is important about this case?

We need to anticipate the patients with unstable bradycardia.

We need to have some sort of plan for what to do with the bradycardia patient who is mostly dead.

We need to discuss this with medical directors ahead of time, so that this does not become a long conversation on a command line while the patient expires or a conversation that ends with an order to Just transport.

This will tell you all you need to know about axis (which is very important) and it should explain better what I am trying to point out. If we understand axis and amplitude, this should be something that immediately gets our attention.

In the February issue of JEMS, Dr. Keith Wesley has a very important article about excited delirium and in custody deaths.

According to the U.S. Department of Justice, 47 states and the District of Columbia reported 1,095 arrest-related deaths from 2003–2005.[1]

Assuming that the 2003-2005 means January 01, 2003 through to December 31, 2005, that means 1,095/3 years or 365 in custody deaths per year. Almost an average of one a day. 2004 was a leap year with 366 days. Maybe leap days exert a protective effect against excited delirium. 🙄

–

Before the proliferation of such less-lethal techniques as CEDs, pepper spray and bean bag rounds, many subjects who were this aggressive met their death from the use of lethal force.[1]

In custody death is nothing new. These deaths just seem less preventable when they are the result of GSWs (Gun Shot Wounds), rather than the now he’s alive – now he’s dead – and he stays dead presentation that is typical for these patients.

–

Current research reveals excited delirium patients have abnormally altered levels of several neurochemicals in their brain—the most important being dopamine.(4)[1]

This can happen even among those not taking stimulant drugs.

–

Elevated levels of dopamine cause agitation, paranoia and violent behavior. Heart rate, respiration and temperature control are also affected by dopamine levels with elevation resulting in tachycardia, tachypnea and hyperthermia. For this reason, hyperthermia is a hallmark of excited delirium.[1]

Kind of like hyperventilation syndrome on crack cocaine.

–

As dopamine levels rise, in combination with the stimulant effects of drugs, the patient’s metabolic activity increases. This results in hyperthermia. The patient becomes acidotic as a result of muscle activity, which has been documented to elevate creatinine phosphokinase—a protein released from muscle death. Metabolic acidosis results in hyperkalemia, which can precipitate dysrhythmias. Therefore, when cardiac arrest occurs, it does so in an environment of severe acidosis and hyperkalemia.(6)[1]

Therefore, when cardiac arrest occurs, it does so in an environment of severe acidosis and hyperkalemia.

It may be a good idea to start treatment with calcium (chloride is preferred, but gluconate can work, too).

Why calcium?

1. If this is a case of hyperkalemia, there is no more effective initial treatment than calcium.

2. If this is a case of hyperkalemia, there is nothing that works as quickly as calcium.

3. Even with immediate ALS (Advanced Life Support), nobody seems to be able to resuscitate these patients, so there does not appear to be anything to lose. How can calcium possibly make things any worse?

The resuscitation rate for witnessed arrests should at least equal the resuscitation rate for the community as a whole. These patients do not respond to conventional ACLS (Advanced Cardiac Life Support). Therefore, these patients should not be treated as conventional cardiac arrest patients.

Given the expectation that these patients are hyperkalemic, is it responsible to treat these patients as anything other than hyperkalemic?

If hyperkalemia is left untreated, a sine-wave pattern, idioventricular rhythms, and asystolic cardiac arrest may develop.203,204[2]

ACLS Modifications in Management of Severe Cardiotoxicity or Cardiac Arrest Due to HyperkalemiaTreatment of severe hyperkalemia aims at protecting the heart from the effects of hyperkalemia by antagonizing the effect of potassium on excitable cell membranes, forcing potassium into cells to remove it promptly from the circulation, and removing potassium from the body. Therapies that shift potassium will act rapidly but are temporary and thus may need to be repeated. In order of urgency, treatment includes the following:

That is the initial treatment for hyperkalemia. That is what EMS should focus on.

Some people will say that we should start with sodium bicarbonate. Ignore them. They do not know what they are talking about. Every responsible organization should make it clear that calcium is the initial treatment for unstable hyperkalemia.

When cardiac arrest occurs secondary to hyperkalemia, it may be reasonable to administer adjuvant IV therapy as outlined above for cardiotoxicity in addition to standard ACLS (Class IIb, LOE C).[3]

Otherwise, there is no reason to believe that these patients will be resuscitated. Similarly, we should focus on calcium when treating cardiac arrest with dialysis patients.

[3]ACLS Modifications in Management of Severe Cardiotoxicity or Cardiac Arrest Due to Hyperkalemia
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 12: Cardiac Arrest in Special Situations
Part 12.6: Cardiac Arrest Associated With Life-Threatening Electrolyte Disturbances
HyperkalemiaFree Full Text From Circulation with link to Free Full Text PDF Download

Ignorance is preferable to error; and he is less remote from the truth who believes nothing, than he who believes what is wrong.

- Thomas Jefferson

Notes on the State of Virginia (1781-1783)

-

Bigotry and science can have no communication with each other, for science begins where bigotry and absolute certainty end. The scientist believes in proof without certainty, the bigot in certainty without proof. Let us never forget that tyranny most often springs from a fanatical faith in the absoluteness of one’s beliefs.

Ashley Montagu.

-

Today we rely less on superstition and tradition than people did in the past, not because we are more rational, but because our understanding of risk enables us to make decisions in a rational mode.

- Peter L. Bernstein

Against the Gods: the remarkable story of risk (1996)

-

Mark my word, if and when these preachers get control of the [Republican] party, and they're sure trying to do so, it's going to be a terrible damn problem. Frankly, these people frighten me. Politics and governing demand compromise. But these Christians believe they are acting in the name of God, so they can't and won't compromise. I know, I've tried to deal with them.

Barry Goldwater.

-

I think every good Christian ought to kick Falwell right in the ass.

Barry Goldwater

Said in July 1981 in response to Moral Majority founder Jerry Falwell's opposition to the nomination of Sandra Day O'Connor to the Supreme Court, of which Falwell had said, "Every good Christian should be concerned." as quoted in Ed Magnuson, "The Brethren's First Sister," Time Magazine, (20 July, 1981)

-

What do you think science is? There's nothing magical about science. It is simply a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results. Which part of that exactly do you disagree with? Do you disagree with being thorough? Using careful observation? Being systematic? Or using consistent logic?

Dr. Steven Novella.

-

What progress we are making. In the Middle Ages they would have burned me. Now they are content with burning my books.

Sigmund Freud (1933)

Today the samizdat is digital and burning a copy has the opposite meaning. A little later, persecution of the Jews was once again the law - Freud's four sisters all died in concentration camps, although not by burning.

-

"Can you prove that it’s impossible?” “No”, I said, “I can’t prove it’s impossible. It’s just very unlikely”. At that he said, “You are very unscientific. If you can’t prove it impossible then how can you say that it’s unlikely?” But that is the way that is scientific. It is scientific only to say what is more likely and what less likely, and not to be proving all the time the possible and impossible. To define what I mean, I might have said to him, "Listen, I mean that from my knowledge of the world that I see around me, I think that it is much more likely that the reports of flying saucers are the results of the known irrational characteristics of terrestrial intelligence than of the unknown rational efforts of extra-terrestrial intelligence." It is just more likely. That is all.

Richard Feynman.

The Character of Physical Law (1965)
chapter 7, “Seeking New Laws,” p. 165-166:

It has been over half century since Feynman explained this. The reports of flying saucers have continued, but there is still no valid evidence to support belief in flying saucers. Feynman's explanation is a good definition of unlikely.

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An ignorant mind is precisely not a spotless, empty vessel, but one that’s filled with the clutter of irrelevant or misleading life experiences, theories, facts, intuitions, strategies, algorithms, heuristics, metaphors, and hunches that regrettably have the look and feel of useful and accurate knowledge.

David Dunning - explaining the Dunning-Kruger effect.

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Treat beliefs not as sacred possessions to be guarded but rather as testable hypotheses to be discarded when the evidence mounts against them.

Philip Tetlock.

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Squatting in between those on the side of reason and evidence and those worshipping superstition and myth is not a better place. It just means you’re halfway to crazy town.

PZ Myers

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The legitimate powers of government extend to such acts only as are injurious to others. But it does me no injury for my neighbour to say there are twenty gods, or no god. It neither picks my pocket nor breaks my leg.

Thomas Jefferson.

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Imagine a world in which we are all enlightened by objective truths rather than offended by them.

Neil deGrasse Tyson

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Education is a progressive discovery of our own ignorance.

Will Durant.

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You don't use science to show that you're right,

you use science to become right.

Randall Munroe

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Just because science doesn't know everything doesn't mean you can fill in the gaps with whatever fairy tale most appeals to you.

There appears to be in mankind an unacceptable prejudice in favor of ancient customs and habitudes which allows practices to continue long after the circumstances, which formerly made them useful, cease to exist

Benjamin Franklin.

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If science proves some belief of Buddhism wrong,

then Buddhism will have to change.

Tenzin Gyatso, 14th Dalai Lama.

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Ridicule is the only weapon which can be used against unintelligible propositions. Ideas must be distinct before reason can act upon them;

Thomas Jefferson.

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Science doesn't make it impossible to believe in God.

It just makes it possible to not believe in God.

Stephen Weinberg.

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There are no forbidden questions in science,

no matters too sensitive or delicate to be probed,

no sacred truths.

Carl Sagan.

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The legitimate powers of government extend to such acts only as are injurious to others. But it does me no injury for my neighbour to say there are twenty gods, or no god. It neither picks my pocket nor breaks my leg.

Thomas Jefferson.

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It is better to not understand something true,
than to understand something false.

Neils Bohr.

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God does not play dice with the universe.

Albert Einstein

Stop telling God what to do with his dice.

response by Neils Bohr.

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All things are poison and nothing is without poison, only the dose permits something not to be poisonous.

Paracelsus.

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What is not true, as everyone knows, is always immensely more fascinating and satisfying to the vast majority of men than what is true.

H.L. Mencken.

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Every valuable human being must be a radical and a rebel, for what he must aim at is to make things better than they are.

Niels Bohr.

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How wonderful that we have met with a paradox. Now we have some hope of making progress.

Niels Bohr.

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An expert is a man who has made all the mistakes which can be made in a very narrow field.

Niels Bohr.

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Every sentence I utter must be understood not as an affirmation, but as a question.

Niels Bohr.

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Some subjects are so serious that one can only joke about them.

Niels Bohr.

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I have no special talents. I am only passionately curious.

Albert Einstein.

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Few people are capable of expressing with equanimity opinions which differ from the prejudices of their social environment. Most people are even incapable of forming such opinions.

Albert Einstein.

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Never memorize what you can look up in books.

Albert Einstein.

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The prestige of government has undoubtedly been lowered considerably by the prohibition law. For nothing is more destructive of respect for the government and the law of the land than passing laws which cannot be enforced. It is an open secret that the dangerous increase of crime in the United States is closely connected with this.

Albert Einstein.

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the chance is high that the truth lies in the fashionable direction. But, on the off-chance that it is in another direction - a direction obvious from an unfashionable view of field theory - who will find it? Only someone who has sacrificed himself by teaching himself quantum electrodynamics from a peculiar and unusual point of view; one that he may have to invent for himself. I say sacrificed himself because he most likely will get nothing from it, because the truth may lie in another direction, perhaps even the fashionable one.

If you've made up your mind to test a theory, or you want to explain some idea, you should always decide to publish it whichever way it comes out. If we only publish results of a certain kind, we can make the argument look good. We must publish both kinds of results.

If a reasonable launch schedule is to be maintained, engineering often cannot be done fast enough to keep up with the expectations of originally conservative certification criteria designed to guarantee a very safe vehicle. In these situations, subtly, and often with apparently logical arguments, the criteria are altered so that flights may still be certified in time. They therefore fly in a relatively unsafe condition, with a chance of failure of the order of a percent (it is difficult to be more accurate).

Official management, on the other hand, claims to believe the probability of failure is a thousand times less. One reason for this may be an attempt to assure the government of NASA perfection and success in order to ensure the supply of funds. The other may be that they sincerely believed it to be true, demonstrating an almost incredible lack of communication between themselves and their working engineers.

Science is a way of trying not to fool yourself. The first principle is that you must not fool yourself, and you are the easiest person to fool.

Richard Feynman.

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Science alone of all the subjects contains within itself the lesson of the danger of belief in the infallibility of the greatest teachers in the preceding generation ... Learn from science that you must doubt the experts. As a matter of fact, I can also define science another way:

Science is the belief in the ignorance of experts.

Richard Feynman.

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The only way to have real success in science, the field I’m familiar with, is to describe the evidence very carefully without regard to the way you feel it should be. If you have a theory, you must try to explain what’s good and what’s bad about it equally. In science, you learn a kind of standard integrity and honesty.

Richard Feynman.

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Some people say, "How can you live without knowing?" I do not know what they mean. I always live without knowing. That is easy. How you get to know is what I want to know.

Richard Feynman.

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I don't know anything, but I do know that everything is interesting if you go into it deeply enough.

Richard Feynman.

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So, to test the prevailing intellectual standards, I decided to try a modest (though admittedly uncontrolled) experiment: Would a leading North American journal of cultural studies . . . publish an article liberally salted with nonsense if (a) it sounded good and (b) it flattered the editors' ideological preconceptions?

Common sense in matters medical is rare, and is usually in inverse ratio to the degree of education.

William Osler.

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The greater the ignorance the greater the dogmatism.

William Osler.

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The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.

William Osler.

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One of the first duties of the physician is to educate the masses not to take medicine.

William Osler.

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In the fields of observation chance favors only the prepared mind.

Louis Pasteur.

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Science knows no country, because knowledge belongs to humanity, and is the torch which illuminates the world. Science is the highest personification of the nation because that nation will remain the first which carries the furthest the works of thought and intelligence.

Louis Pasteur.

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Not far from the invention of fire must rank the invention of doubt.

Thomas Henry Huxley.

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The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact.

Thomas Henry Huxley.

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The foundation of morality is to have done, once and for all, with lying; to give up pretending to believe that for which there is no evidence, and repeating unintelligible propositions about things beyond the possibilities of knowledge.

Thomas Henry Huxley.

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My business is to teach my aspirations to conform themselves to fact, not to try and make facts harmonise with my aspirations.

Thomas Henry Huxley.

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There must have been a time, in the beginning, when we could have said – no. But somehow we missed it.

Tom Stoppard

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All men can be criminals, if tempted; all men can be heroes, if inspired.

G. K. Chesterton

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There is no such thing on earth as an uninteresting subject; the only thing that can exist is an uninterested person.

G. K. Chesterton

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Good taste, the last and vilest of human superstitions, has succeeded in silencing us where all the rest have failed.

G. K. Chesterton

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Men become superstitious, not because they have too much imagination, but because they are not aware that they have any.

George Santayana

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If we are uncritical we shall always find what we want: we shall look for, and find, confirmations, and we shall look away from, and not see, whatever might be dangerous to our pet theories. In this way it is only too easy to obtain what appears to be overwhelming evidence in favor of a theory which, if approached critically, would have been refuted.

Karl Popper

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It is difficult to get a man to understand something, when his salary depends upon his not understanding it!

Upton Sinclair

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Freedom is what you do with what's been done to you.

Jean-Paul Sartre

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Where goods do not cross frontiers, armies will.

Frédéric Bastiat

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The ultimate result of shielding men from the effects of folly is to ﬁll the world with fools.

Herbert Spencer

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Political language — and with variations this is true of all political parties, from Conservatives to Anarchists — is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind.

George Orwell

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Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passion, they cannot alter the state of facts and evidence.

John Adams

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We're not presuming the answers before we ask the questions.

Lawrence Krauss explaining how science works

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Malo Periculosam Libertatem Quam Quietum Servitium.

Better freedom with danger than peace with slavery.

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Whatever inspiration is, it's born from a continuous "I don't know."

Wislawa Szymborska

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All sorts of torturers, dictators, fanatics, and demagogues struggling for power by way of a few loudly shouted slogans also enjoy their jobs, and they too perform their duties with inventive fervor.

Well, yes, but they "know." They know, and whatever they know is enough for them once and for all.

They don't want to find out about anything else, since that might diminish their arguments' force.

Wislawa Szymborska.

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Theory helps us to bear our ignorance of fact.

George Santayana

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Miracles are propitious accidents, the natural causes of which are too complicated to be readily understood.

George Santayana.

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Fanaticism consists in redoubling your efforts when you have forgotten your aim.

George Santayana

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There is a fundamental difference between religion,

which is based on authority,

and science,

which is based on observation and reason.

Science will win because it works.

Stephen Hawking.

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The truth, indeed, is something that mankind, for some mysterious reason, instinctively dislikes. Every man who tries to tell it is unpopular, and even when, by the sheer strength of his case, he prevails, he is put down as a scoundrel.

H.L. Mencken.

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It is the natural tendency of the ignorant to believe what is not true. In order to overcome that tendency it is not sufficient to exhibit the true; it is also necessary to expose and denounce the false.

I am attempting to make it easier, when I use footnotes, to navigate to the information in a footnote, look at the information, and return to where you were before you clicked on the footnote. If you click on the number of a footnote in the text[1] <- click on the bracketed and underlined number - in this case [1], it will bring the footnote to the top of the screen.

[1] If you click on the bracketed and underlined number of a footnote in footnote section, the [1] at the beginning of this paragraph, it will take you to where you clicked on the footnote in the text, with the footnote along the top of the screen. [To top of footnotes]

If you wish to modify the size of the text, you can press the CTRL key and roll the mouse wheel forward or back, or you can press the CTRL key and the + or - keys to make text larger or smaller. Another way is to adjust the font in your browser controls.

This is a mostly medical blog, so here is the HIPAA incantation to ward off evil whiny HIPAA-obsessed spirits.

HIPAA (Health Insurance Portability and Accountability Act of 1996) is generally misrepresented by those in health care, but there are no violations of HIPAA here. There are some patients I could not discuss without changing details, so details may be omitted, or changed. That may decrease the dramatic effect of some of what I write, but patients are entitled to their privacy and have been since before HIPAA became the ignorant administrators' justification for imitating a two year old yelling NO!

I am not dispensing medical advice. If you get your medical advice off of a blog, instead of consulting a physician (such as your medical director), you probably should not be treating anyone, not even yourself. I could include your dog, but that would suggest that veterinarians do not provide excellent care. The veterinarians I know take pride in the care they deliver and deliver excellent care, more so than many people I know in EMS.

I do point you to research to support what I write, but you still need to make sure that you have the authorization of your medical director before changing any of your treatments. If your medical director does not agree, you can point to the research I write about. Most doctors do understand research, they just have trouble keeping up with the amount of research that is produced.

What I write does not change your protocols. If you do not like a protocol, take it up with the medical director. I have several inadequate protocols, too. I call medical command and attempt to persuade the physician that what I am requesting is in the best interest of the patient. It is rare that I am turned down, but the dose is often inadequate. I call back before I need more, so the patient does not have to put up with the On Line Medical Command delay in treatment. Health care providers should be anticipating where the care of the patient is headed - both for good and for bad.

I do not have any connection to the products I mention, other than using them and being satisfied, dissatisfied, or some combination of the two. If I have any potential conflict of interest, I will mention it clearly.

If I write about a book by an author I know, I will encourage you to buy the book from the author's web site. This means that any money goes to the author (or to where the author wants the money to go, such as a charity) and you have an opportunity to sample the author's writing for free on the author's blog before buying the book.

I may be blunt, but I do not intend it personally. There are few mistakes that can be made that I have not made. I continue to try not to be stupid; you may conclude that I fail.

I welcome any relevant comments and much that is not relevant. I reserve the right to delete any inappropriate comments. I decide what is appropriate based on my own nebulous standards. Criticism of ideas is expected. Criticism of writing style is appreciated.

I avoid obscenity because I believe that the English language provides enough opportunities for creativity that resorting to the words that may not be said on TV (and a growing group of words that may) is unnecessary. I may quote something that contains some of these words, or I may link to something that does, but that is as bad as I expect to be with these words.

On the other hand, you may feel that the ideas I present are offensive. My aim is to encourage thought, dialogue, and creativity - not to tell you everything is OK. You may leave this blog at any time and bury your mind in comfortable, familiar ideas.

If you feel that the ideas I present are not challenging, please encourage me to address whatever you feel I do not adequately address.